Basic Information
Provider Information
NPI: 1003001314
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PALMGREN
FirstName: JOHANNA
MiddleName: LYNN
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: PALMGREN
OtherFirstName: JOHANNA
OtherMiddleName: LYNN
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: RN
OtherLastNameType: 5
Mailing Information
Address1: PO BOX 1337
Address2:  
City: GALLUP
State: NM
PostalCode: 873051337
CountryCode: US
TelephoneNumber: 5057221000
FaxNumber: 5057221310
Practice Location
Address1: 516 NIZHONI BLVD
Address2:  
City: GALLUP
State: NM
PostalCode: 873015748
CountryCode: US
TelephoneNumber: 5057221000
FaxNumber: 5057221310
Other Information
ProviderEnumerationDate: 09/10/2007
LastUpdateDate: 02/13/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163WA2000XRN16330MTY Nursing Service ProvidersRegistered NurseAdministrator

No ID Information.


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